Dangerous TB Patient Detained on U.S. Border

By

Betsy McKay

March 1, 2013

In medical isolation in South Texas, 100 miles or so from Mexico's border, is a man who embodies one of U.S. health officials' greatest worries: He is the first person to cross and be held in detention while infected with one of the most severe types of drug-resistant tuberculosis known today.

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His three-month odyssey through 13 countries—from his homeland of Nepal through South Asia, Brazil, Mexico, and finally into Texas—shows the way in which dangerous new strains of the disease can migrate across the world unchecked.

Tuberculosis, an ancient, fatal airborne disease, has been treatable for decades with a cocktail of drugs. However, shoddy medical practices world-wide have enabled the bacteria to mutate and, in some cases, become all but untreatable. In recent months The Wall Street Journal has exposed widening TB drug resistance in hot spots like India, and shown that the U.S. is surprisingly unprepared for the growing global problem. Most U.S. cases of drug-resistant TB occur in people who were born abroad, according to the Centers for Disease Control and Prevention.

ENLARGE

The Nepalese man detained at the U.S. border carries a particularly deadly strain—XDR, "extensively drug-resistant" TB. His TB is resistant to at least eight of the 15 or so standard drugs, according to a U.S. government description of the case reviewed by the Journal. His XDR strain has been seen only once before in the U.S., in another patient of Nepalese origin, according to the government description.

The Nepalese patient was taken into custody by the U.S. Border Patrol in late November as he tried to cross the border illegally near McAllen, Texas, according to Department of Homeland Security officials. The government declined to name him.

He was transferred five days later to an Immigration and Customs Enforcement detention facility in Los Fresnos, Texas, and put into "medical isolation" with suspected tuberculosis, according to ICE. He has since been moved to another ICE detention facility, in Pearsall, Texas, with more medical staff, ICE said. He is the first XDR-case in ICE custody.

In-Depth: A Killer Quietly Gains Strength

The Wall Street Journal is chronicling the world's imperfect response to the rise of drug-resistant tuberculosis, an ancient disease that modern medicine, until recently, could defeat.

India's slow reaction appears to be nurturing an all-but-untreatable strain of TB, raising the prospect of a global health hazard. (6/20/12)

A top doctor in Mumbai reports finding 12 cases of tuberculosis that are all but untreatable by current methods. (1/19/12)

Twelve Border Patrol agents were tested for the disease, but none contracted it from the patient, a Customs and Border Protection official said. Casual contact doesn't necessarily lead to infection, though it depends in part on how much time is spent in tight quarters with a patient, and how much the patient coughs, spreading bacteria into the air.

It remains unclear whether other people in custody with the Nepalese detainee might have been infected. By the time the Border Patrol learned of his infection, other people detained with him would have been transferred elsewhere, the CBP official said. Detainees who are suspected of being ill are placed in cells by themselves.

Given how far and wide the patient ventured—he took a flight of more than eight hours to Brazil, and also traveled by car, boat and on foot—his case was reported to the World Health Organization as having potentially widespread public-health impact. Now, officials in the 13 countries the man visited along the way must try to track down thousands of people he likely came into contact with, to see if any were infected.

That will be a challenge. "We will try to investigate where he was," said Martin Castellanos, director of Mexico's national TB program. But reconstructing his precise route through Mexico, or any country, will be difficult and perhaps impossible, he said.

Dr. Castellanos says he was told the man spent time in a migrant community in Reynosa, across the border from Texas. But migrants typically linger there only "for a week, two weeks," he said, before moving on. "For sure, no one who was there in November is there now," he said.

The WHO's Stop TB Department said it is working with the CDC to inform affected countries about people who may have been exposed to the man. It is also trying to get more details on potentially infected people in those countries who have been reached by local authorities.

DHS and the CDC declined to discuss details of the man's case, citing patient privacy. The man declined an interview request from the Journal made through ICE. He also declined to sign a privacy waiver allowing officials to release details of his treatment and his immigration case, ICE said.

ENLARGE

A U.S. Customs and Border Protection vehicle passes along the U.S.-Mexico border fence in Brownsville, Texas.
AP

XDR-TB is a particularly dangerous form of the disease that is resistant not only to the two most potent TB drugs, but also a handful of second-line drugs. It is rare in the U.S.: Only six cases were reported in 2011, according to the CDC.

But it is a growing threat in countries including India and South Africa, where it has been found all over the country. The risk to the world is that the disease will migrate outward from these hot spots. Treatment options for XDR-TB are limited and can themselves be toxic.

ICE officials screen patients for TB—both regular and multidrug-resistant varieties—when they arrive at a detention facility. "We prepare for it and look for it," an ICE medical official said. They find one or two cases of multidrug-resistant TB a year, the official said.

How long the man will remain in care in the U.S. is unclear. Treatment can last for years, but TB patients aren't infectious for the entire course of treatment.

Detainee patients aren't normally kept until they are completely cured. However, infectious patients aren't deported on commercial flights or by any other means that "could be a danger to anyone," the official said.

One risk, of course, is that a patient won't have enough drugs or medical expertise to complete the treatment he or she needs once deported to another country. TB strains can become increasingly drug-resistant if a patient's treatment regimen is interrupted, even briefly. This is one way that drug-resistant TB has emerged over time.

The Migrant Clinicians Network, an Austin, Texas, nongovernmental organization, helps arrange for deported patients to continue their treatment in their home countries. U.S. officials also often send patients home with a supply of the TB drugs they need, particularly to countries where supplies are uneven.

Arranging care for drug-resistant patients is complicated, said Ed Zuroweste, the Migrant Clinicians Network's chief medical officer. "XDR is hugely difficult," he said. "You really have to have experts to treat someone like that."

Nepal is known for innovative health programs, including some to fight TB. But like many countries, it has struggled with drug-resistant forms. Nepal reported more than 35,000 TB cases in 2011, and 2.9% of new and 12% of previously-treated TB cases are multidrug-resistant, according to WHO data.

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